Prevalence of health behaviors among cancer survivors in the United States

PURPOSE

We determined the proportion of cancer survivors who met each of five health behavior guidelines recommended by the American Cancer Society (ACS), including consuming fruits and vegetables at least five times/day, maintaining a body mass index (BMI) < 30 kg/m2, engaging in 150 min or more of physical activity weekly, not currently smoking, and not excessively drinking alcohol.

METHODS

Using data from the 2019 Behavioral Risk Factor Surveillance System (BRFSS), 42,727 survey respondents who reported a previous diagnosis of cancer (excluding skin cancer) were included. Weighted percentages with 95% confidence intervals (95% CI) were estimated for the five health behaviors accounting for BRFSS' complex survey design.

RESULTS

The weighted percentage of cancer survivors who met ACS guidelines was 15.1% (95%CI: 14.3%, 15.9%) for fruit and vegetable intake; 66.8% (95%CI: 65.9%, 67.7%) for BMI < 30 kg/m2; 51.1% (95%CI: 50.1%, 52.1%) for physical activity; 84.9% (95%CI: 84.1%, 85.7%) for not currently smoking; and 89.5% (95%CI: 88.8%, 90.3%) for not drinking excessive alcohol. Adherence to ACS guidelines among cancer survivors generally increased with increasing age, income, and education.

CONCLUSIONS

While the majority of cancer survivors met the guidelines for not smoking and limiting alcohol drinking, one-third had elevated BMI, almost half did not meet recommended physical activity levels, and the majority had inadequate fruit and vegetable intake.

IMPLICATIONS FOR CANCER SURVIVORS

Adherence to guidelines was lowest among younger cancer survivors and those with lower income and education, suggesting these may be populations where resources could be targeted to have the greatest impact.

Chronic Disease Prevalence in the US: Sociodemographic and Geographic Variations by Zip Code Tabulation Area

Introduction

We examined the geographic distribution and sociodemographic and economic characteristics of chronic disease prevalence in the US. Understanding disease prevalence and its impact on communities is crucial for effective public health interventions.

Methods

Data came from the American Community Survey, the American Hospital Association Survey, and the Centers for Disease Control and Prevention's PLACES. We used quartile thresholds for 10 chronic diseases to assess chronic disease prevalence by Zip Code Tabulation Areas (ZCTAs). ZCTAs were scored from 0 to 20 based on their chronic disease prevalence quartile. Three prevalence categories were established: least prevalent (score ≤6), moderately prevalent (score 7-13), and highest prevalence (score ≥14). Community characteristics were compared across categories and spatial analyses to identify clusters of ZCTAs with high disease prevalence.

Results

Our study showed a high prevalence of chronic disease in the southeastern region of the US. Populations in ZCTAs with the highest prevalence showed significantly greater socioeconomic disadvantages (ie, lower household income, lower home value, lower educational attainment, and higher uninsured rates) and barriers to health care access (lower percentage of car ownership and longer travel distances to hospital-based intensive care units, emergency departments, federally qualified health centers, and pharmacies) compared with ZCTAs with the lowest prevalence.

Conclusion

Socioeconomic disparities and health care access should be addressed in communities with high chronic disease prevalence. Carefully directed resource allocation and interventions are necessary to reduce the effects of chronic disease on these communities. Policy makers and clinicians should prioritize efforts to reduce chronic disease prevalence and improve the overall health and well-being of affected communities throughout the US.

Measuring Variation in Infant Mortality and Deaths of Despair by U.S. Congressional Districts in Pennsylvania: A Methodological Case Study

Many ecological studies examine health outcomes and disparities using administrative boundaries such as census tracts, counties, or states. These boundaries help us to understand the patterning of health by place along with impacts of policies implemented at these levels. However, additional geo-political units, or units with both geographic and political meaning, such as congressional districts, present further opportunities to connect research with public policy. We provide a step-by-step guide in how to conduct disparities-focused analysis at the congressional district level, and as an applied case study we use geocoded vital statistics data from 2010-2015 to examine levels and disparities of infant mortality (IM) and deaths of despair (DoD) in the 19 U.S. congressional districts of Pennsylvania for the 111th-112th (2009-2012) Congresses, and 18 districts for the 113th-114th (2013-2016) Congresses. We also provide recommendations for extending congressional district level analysis to other outcomes, states, and geopolitical boundaries such as state legislative districts. Increased surveillance of health outcomes at the congressional district level can help prompt policy action, advocacy, and hopefully, reduce rates and disparities in health.

Predictors of Autism Spectrum Disorder and ADHD: Results from the National Survey of Children's Health

BACKGROUND

Autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) are two of the most common neurodevelopmental disorders with comorbidity rates of up to 70%. Population-based studies show differential rates of ADHD and ASD diagnosis based on sociodemographic variables. However, no studies to date have examined the role of sociodemographic factors on the likelihood of receiving an ADHD, ASD, or comorbid ASD + ADHD diagnosis in a large, nationally representative sample.

OBJECTIVE

This study aims to examine the impact of sociodemographic factors on the odds of experiencing ASD-only, ADHD-only, or both diagnoses for children in the United States.

METHODS

Using a mixed effects multinomial logistic modeling approach and data from the 2016-2018 National Survey of Children's Health, we estimated the association between sociodemographic variables and the log odds of being in each diagnostic group.

RESULTS

Sociodemographic variables were differentially related to the three diagnostic groups: ASD-only, ADHD-only, and ASD + ADHD. Compared to girls, boys experienced higher odds of all three diagnosis categories. White children had higher odds of having an ADHD-only or ASD + ADHD diagnosis compared to non-Hispanic (NH) Black, NH multiple/other race, and Hispanic children. Odds ratios for levels of parent education, household income, and birth characteristics showed varying trends across diagnostic groups.

CONCLUSIONS

Overall, our findings point to unique sets of risk factors differentially associated ASD and ADHD, with lower income standing out as an important factor associated with receiving a diagnosis of ASD + ADHD.

Effect of rurality and travel distance on contralateral prophylactic mastectomy for unilateral breast cancer

PURPOSE

Despite lack of survival benefit, demand for contralateral prophylactic mastectomy (CPM) to treat unilateral breast cancer remains high. High uptake of CPM has been demonstrated in Midwestern rural women. Greater travel distance for surgical treatment is associated with CPM. Our objective was to examine the relationship between rurality and travel distance to surgery with CPM.

METHODS

Women diagnosed with stages I-III unilateral breast cancer between 2007 and 2017 were identified using the National Cancer Database. Logistic regression was used to model likelihood of CPM based on rurality, proximity to metropolitan centers, and travel distance. A multinomial logistic regression model compared factors associated with CPM with reconstruction versus other surgical options.

RESULTS

Both rurality (OR 1.10, 95% CI 1.06-1.15 for non-metro/rural vs. metro) and travel distance (OR 1.37, 95% CI 1.33-1.41 for those who traveled 50 + miles vs. < 30 miles) were independently associated with CPM. For women who traveled 30 + miles, odds of receiving CPM were highest for non-metro/rural women (OR 1.33 for 30-49 miles, OR 1.57 for 50 + miles; reference: metro women traveling < 30 miles). Non-metro/rural women who received reconstruction were more likely to undergo CPM regardless of travel distance (ORs 1.11-1.21). Both metro and metro-adjacent women who received reconstruction were more likely to undergo CPM only if they traveled 30 + miles (ORs 1.24-1.30).

CONCLUSION

The impact of travel distance on likelihood of CPM varies by patient rurality and receipt of reconstruction. Further research is needed to understand how patient residence, travel burden, and geographic access to comprehensive cancer care services, including reconstruction, influence patient decisions regarding surgery.

Measuring and addressing health equity: an assessment of cancer center designation requirements

PURPOSE

By requiring specific measures, cancer endorsements (e.g., accreditations, designations, certifications) promote high-quality cancer care. While 'quality' is the defining feature, less is known about how these endorsements consider equity. Given the inequities in access to high-quality cancer care, we assessed the extent to which equity structures, processes, and outcomes were required for cancer center endorsements.

METHODS

We performed a content analysis of medical oncology, radiation oncology, surgical oncology, and research hospital endorsements from the American Society of Clinical Oncology (ASCO), American Society of Radiation Oncology (ASTRO), American College of Surgeons Commission on Cancer (CoC), and the National Cancer Institute (NCI), respectively. We analyzed requirements for equity-focused content and compared how each endorsing body included equity as a requirement along three axes: structures, processes, and outcomes.

RESULTS

ASCO guidelines centered on processes assessing financial, health literacy, and psychosocial barriers to care. ASTRO guidelines related to language needs and processes to address financial barriers. CoC equity-related guidelines focused on processes addressing financial and psychosocial concerns of survivors, and hospital-identified barriers to care. NCI guidelines considered equity related to cancer disparities research, inclusion of diverse groups in outreach and clinical trials, and diversification of investigators. None of the guidelines explicitly required measures of equitable care delivery or outcomes beyond clinical trial enrollment.

CONCLUSION

Overall, equity requirements were limited. Leveraging the influence and infrastructure of cancer quality endorsements could enhance progress toward achieving cancer care equity. We recommend that endorsing organizations 1) require cancer centers to implement processes for measuring and tracking health equity outcomes and 2) engage diverse community stakeholders to develop strategies for addressing discrimination.

Equitable implementation of lung cancer screening: avoiding its potential to mirror existing inequities among people who use tobacco

PURPOSE

Lung cancer is the leading cause of cancer death, but the advent of lung cancer screening using low-dose computed tomography offers a tremendous opportunity to improve lung cancer outcomes. Unfortunately, implementation of lung cancer screening has been hampered by substantial barriers and remains suboptimal. Specifically, the commentary emphasizes the intersectionality of smoking history and several important sociodemographic characteristics and identities that should inform lung cancer screening outreach and engagement efforts, including socioeconomic considerations (e.g., health insurance status), racial and ethnic identity, LGBTQ + identity, mental health history, military experience/veteran status, and geographic residence in addressing specific community risk factors and future interventions in efforts to make strides toward equitable lung cancer screening.

METHODS

Members of the Equitable Implementation of Lung Cancer Screening Interest Group with the Cancer Prevention and Control Network (CPCRN) provide a critical commentary based on existing literature regarding smoking trends in the US and lung cancer screening uptake to propose opportunities to enhance implementation and support equitable distribution of the benefits of lung cancer screening.

CONCLUSION

The present commentary utilizes information about historical trends in tobacco use to highlight opportunities for targeted outreach efforts to engage communities at high risk with information about the lung cancer screening opportunity. Future efforts toward equitable implementation of lung cancer screening should focus on multi-level implementation strategies that engage and work in concert with community partners to co-create approaches that leverage strengths and reduce barriers within specific communities to achieve the potential of lung cancer screening.

Prioritizing rural populations in state comprehensive cancer control plans: a qualitative assessment

PURPOSE

The Centers for Disease Control and Prevention's National Comprehensive Cancer Control Program (NCCCP) requires that states develop comprehensive cancer control (CCC) plans and recommends that disparities related to rural residence are addressed in these plans. The objective of this study was to explore rural partner engagement and describe effective strategies for incorporating a rural focus in CCC plans.

METHODS

States were selected for inclusion using stratified sampling based on state rurality and region. State cancer control leaders were interviewed about facilitators and barriers to engaging rural partners and strategies for prioritizing rural populations. Content analysis was conducted to identify themes across states.

RESULTS

Interviews (n = 30) revealed themes in three domains related to rural inclusion in CCC plans. The first domain (barriers) included (1) designing CCC plans to be broad, (2) defining "rural populations," and (3) geographic distance. The second domain (successful strategies) included (1) collaborating with rural healthcare systems, (2) recruiting rural constituents, (3) leveraging rural community-academic partnerships, and (4) working jointly with Native nations. The third domain (strategies for future plan development) included (1) building relationships with rural communities, (2) engaging rural constituents in planning, (3) developing a better understanding of rural needs, and (4) considering resources for addressing rural disparities.

CONCLUSION

Significant relationship building with rural communities, resource provision, and successful strategies used by others may improve inclusion of rural needs in state comprehensive cancer control plans and ultimately help plan developers directly address rural cancer health disparities.

Financial navigation: Staff perspectives on patients' financial burden of cancer care

PURPOSE

To describe perceptions of financial navigation staff concerning patients' cancer-related financial burden.

METHODS

This qualitative descriptive study used a semi-structured interview guide to examine perceptions of financial navigation staff concerning patients' cancer-related financial burden. Staff who provided financial navigation support services to cancer patients were interviewed from different types of cancer programs across seven states representing rural, micropolitan, and urban settings. Interviews lasted approximately one hour, were audio recorded, and transcribed. Transcripts were double coded for thematic analysis.

RESULTS

Thirty-five staff from 29 cancer centers were interviewed. The first theme involved communication issues related to patient and financial navigation staff expectations, timing and the sensitive nature of financial discussions. The second theme involved the multi-faceted impact of financial burden on patients, including stress, difficulty adhering to treatments, and challenges meeting basic, non-medical needs. CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS: Cancer-related financial burden has a profound impact on cancer survivors' health and non-health outcomes. Discussions regarding cancer-related costs between cancer survivors and healthcare team members could help to normalize conversations and mitigate the multi-faceted determinants and effects of cancer-related financial burden. As treatment may span months and years and unexpected costs arise, having this discussion regularly and systematically is needed.

Successes and Barriers of Health Information Exchange Participation Across Hospitals in South Carolina From 2014 to 2020: Longitudinal Observational Study

BACKGROUND

The 2009 Health Information Technology for Economic and Clinical Health Act sets three stages of Meaningful Use requirements for the electronic health records incentive program. Health information exchange (HIE) technologies are critical in the meaningful use of electronic health records to support patient care coordination. However, HIE use trends and barriers remain unclear across hospitals in South Carolina (SC), a state with the earliest HIE implementation.

OBJECTIVE

This study aims to explore changes in the proportion of HIE participation and factors associated with HIE participation, and barriers to exchange and interoperability across SC hospitals.

METHODS

This study derived data from a longitudinal data set of the 2014-2020 American Hospital Association Information Technology Supplement for 69 SC hospitals. The primary outcome was whether a hospital participated in HIE in a year. A cross-sectional multivariable logistic regression model, clustered at the hospital level and weighted by bed size, was used to identify factors associated with HIE participation. The second outcome was barriers to sending, receiving, or finding patient health information to or from other organizations or hospital systems. The frequency of hospitals reporting each barrier related to exchange and interoperability were then calculated.

RESULTS

Hospitals in SC have been increasingly participating in HIE, improving from 43% (24/56) in 2014 to 82% (54/66) in 2020. After controlling for other hospital factors, teaching hospitals (adjusted odds ratio [AOR] 3.7, 95% CI 1.0-13.3), system-affiliated hospitals (AOR 6.6, 95% CI 3.2-13.7), and rural referral hospitals (AOR 8.0, 95% CI 1.2-53.4) had higher odds to participate in HIE than their counterparts, whereas critical access hospitals (AOR 0.1, 95% CI 0.02-0.6) were less likely to participate in HIE than their counterparts reimbursed by the prospective payment system. Hospitals with greater ratios of Medicare or Medicaid inpatient days to total inpatient days also reported higher odds of HIE participation. Despite the majority of hospitals reporting HIE participation in 2020, barriers to exchange and interoperability remained, including lack of provider contacts (27/40, 68%), difficulty in finding patient health information (27/40, 68%), adapting different vendor platforms (26/40, 65%), difficulty matching or identifying same patients between systems (23/40, 58%), and providers that do not typically exchange patient data (23/40, 58%).

CONCLUSIONS

HIE participation has been widely adopted in SC hospitals. Our findings highlight the need to incentivize optimization of HIE and seamless information exchange by facilitating and implementing standardization of health information across various HIE systems and by addressing other technical issues, including providing providers' addresses and training HIE stakeholders to find relevant information. Policies and efforts should include more collaboration with vendors to reduce platform compatibility issues and more user engagement and technical training and support to facilitate effective, accurate, and efficient exchange of provider contacts and patient health information.

The COVID-19 pandemic impact on independent and provider-based rural health clinics' operations and cancer prevention and screening provision in the United States

INTRODUCTION

The COVID-19 pandemic has disrupted cancer care, but it is unknown how the pandemic has affected care in Medicare-certified rural health clinics (RHCs) where cancer prevention and screening services are critical for their communities. This study examined how the provision of these cancer services changed pre- and peri-pandemic overall and by RHC type (independent and provider-based).

METHODS

We administered a cross-sectional survey to a stratified random sample of RHCs to assess clinic characteristics, pandemic stressors, and the provision of cancer prevention and control services among RHCs pre- and peri-pandemic. We used McNemar's test and Wilcoxon signed rank tests to assess differences in the provision of cancer prevention and screening services pre- and peri-pandemic by RHC type.

RESULTS

Of the 153 responding RHCs (response rate of 8%), 93 (60.8%) were provider-based and 60 (39.2%) were independent. Both RHC types were similar in their experience of pandemic stressors, though a higher proportion of independent RHCs reported financial concerns and challenges obtaining personal protective equipment. Both types of RHCs provided fewer cancer prevention and screening services peri-pandemic-5.8 to 4.2 for provider-based and 5.3 to 3.5 for independent (P<.05 for both). Across lung, cervical, breast, and colorectal cancer-related services, the proportion of both RHC groups providing services dropped peri-pandemic.

DISCUSSION

The pandemic's impact on independent and provider-based RHCs and their patients was considerable. Going forward, greater resources should be targeted to RHCs-particularly independent RHCs-to ensure their ability to initiate and sustain evidence-based prevention and screening services.

Evaluation of Bayesian spatiotemporal infectious disease models for prospective surveillance analysis

BACKGROUND

COVID-19 brought enormous challenges to public health surveillance and underscored the importance of developing and maintaining robust systems for accurate surveillance. As public health data collection efforts expand, there is a critical need for infectious disease modeling researchers to continue to develop prospective surveillance metrics and statistical models to accommodate the modeling of large disease counts and variability. This paper evaluated different likelihoods for the disease count model and various spatiotemporal mean models for prospective surveillance.

METHODS

We evaluated Bayesian spatiotemporal models, which are the foundation for model-based infectious disease surveillance metrics. Bayesian spatiotemporal mean models based on the Poisson and the negative binomial likelihoods were evaluated with the different lengths of past data usage. We compared their goodness of fit and short-term prediction performance with both simulated epidemic data and real data from the COVID-19 pandemic.

RESULTS

The simulation results show that the negative binomial likelihood-based models show better goodness of fit results than Poisson likelihood-based models as deemed by smaller deviance information criteria (DIC) values. However, Poisson models yield smaller mean square error (MSE) and mean absolute one-step prediction error (MAOSPE) results when we use a shorter length of the past data such as 7 and 3 time periods. Real COVID-19 data analysis of New Jersey and South Carolina shows similar results for the goodness of fit and short-term prediction results. Negative binomial-based mean models showed better performance when we used the past data of 52 time periods. Poisson-based mean models showed comparable goodness of fit performance and smaller MSE and MAOSPE results when we used the past data of 7 and 3 time periods.

CONCLUSION

We evaluate these models and provide future infectious disease outbreak modeling guidelines for Bayesian spatiotemporal analysis. Our choice of the likelihood and spatiotemporal mean models was influenced by both historical data length and variability. With a longer length of past data usage and more over-dispersed data, the negative binomial likelihood shows a better model fit than the Poisson likelihood. However, as we use a shorter length of the past data for our surveillance analysis, the difference between the Poisson and the negative binomial models becomes smaller. In this case, the Poisson likelihood shows robust posterior mean estimate and short-term prediction results.

Changing recommendations for lung cancer screening: National Lung Cancer Roundtable member perspectives

Although the revised (2021) US Preventive Services Task Force recommendations for lung cancer screening offer the opportunity to save more lives and reduce disparities, National Lung Cancer Roundtable members share a cautionary message about the challenges ahead. To facilitate high‐quality care for diverse populations, a patient‐centered approach is needed that incorporates high‐quality shared decision‐making, improved access to care and navigation, and more streamlined systems of care.

Implementation During a Pandemic: Findings, Successes, and Lessons Learned from Community Grantees

Funding communities through mini-grant programs builds community capacity by fostering leadership among community members, developing expertise in implementing evidence-based practices, and increasing trust in partnerships. The South Carolina Cancer Prevention and Control Research Network (SC-CPCRN) implemented the Community Health Intervention Program (CHIP) mini-grants initiative to address cancer-related health disparities among high-risk populations in rural areas of the state. One community-based organization and one faith-based organization were funded during the most recent call for proposals. The organizations implemented National Cancer Institute evidence-based strategies and programs focused on health and cancer screenings and physical activity and promotion of walking trails. Despite the potential for the COVID-19 pandemic to serve as a major barrier to implementation, grantees successfully recruited and engaged community members in evidence-based activities. These initiatives added material benefits to their local communities, including promotion of walking outdoors where it is less likely to contract the virus when socially distanced and provision of COVID-19 testing and vaccines along with other health and cancer screenings. Future mini-grants programs will benefit from learning from current grantees' flexibility in program implementation during a pandemic as well as their intentional approach to modifying program aspects as needed.

County-Level Prevalence Estimates of Autism Spectrum Disorder in Children in the United States

Prevalence estimates of autism spectrum disorder (ASD) point to geographic and socioeconomic disparities in identification and diagnosis. Estimating national prevalence rates can limit understanding of local disparities, especially in rural areas where disproportionately higher rates of poverty and decreased healthcare access exist. Using a small area estimation approach from the 2016-2018 National Survey of Children's Health (N = 70,913), we identified geographic differences in ASD prevalence, ranging from 4.38% in the Mid-Atlantic to 2.71% in the West South-Central region. Cluster analyses revealed "hot spots" in parts of the Southeast, East coast, and Northeast. This geographic clustering of prevalence estimates suggests that local or state-level differences in policies, service accessibility, and sociodemographics may play an important role in identification and diagnosis of ASD.County-Level Prevalence Estimates of Autism Spectrum Disorder in Children in the United States.

Outcomes of Shared Decision-Making for Low-Dose Screening for Lung Cancer in an Academic Medical Center

Shared decision-making (SDM) helps patients weigh risks and benefits of screening approaches. Little is known about SDM visits between patients and healthcare providers in the context of lung cancer screening. This study explored the extent that patients were informed by their provider of the benefits and harms of lung cancer screening and expressed certainty about their screening choice. We conducted a survey with 75 patients from an academic medical center in the Southeastern U.S. Survey items included knowledge of benefits and harms of screening, patients' value elicitation during SDM visits, and decisional certainty. Patient and provider characteristics were collected through electronic medical records or self-report. Descriptive statistics, Kruskal-Wallis tests, and Pearson correlations between screening knowledge, value elicitation, and decisional conflict were calculated. The sample was predominately non-Hispanic White (73.3%) with no more than high school education (53.4%) and referred by their primary care provider for screening (78.7%). Patients reported that providers almost always discussed benefits of screening (81.3%), but infrequently discussed potential harms (44.0%). On average, patients had low knowledge about screening (score = 3.71 out of 8) and benefits/harms. Decisional conflict was low (score = - 3.12) and weakly related to knowledge (R= - 0.25) or value elicitation (R= - 0.27). Black patients experienced higher decisional conflict than White patients (score = - 2.21 vs - 3.44). Despite knowledge scores being generally low, study patients experienced low decisional conflict regarding their decision to undergo lung cancer screening. Additional work is needed to optimize the quality and consistency of information presented to patients considering screening.

County-level prevalence estimates of ADHD in children in the United States

PURPOSE

Attention-deficit/hyperactivity disorder (ADHD) is a common childhood disorder often characterized by long-term impairments in family, academic, and social settings. Measuring the prevalence of ADHD is important as treatment options increase around the U.S. Prevalence data helps inform decisions by care providers, policymakers, and public health officials about allocating resources for ADHD. In addition, measuring geographic variation in prevalence estimates can facilitate hypothesis generation for future analytic work. Most U.S. studies of ADHD prevalence among children focus on national or demographic group rates.

METHODS

Using a small area estimation approach and data from the 2016 to 2018 National Survey of Children's Health, we estimated childhood ADHD prevalence estimates at the census regional division, state, and county levels. The sample included approximately 70,000 children aged 5-17 years.

RESULTS

The national ADHD rate was estimated to be 12.9% (95% Confidence Interval: 11.5%, 14.4%). Counties in the West South Central, East South Central, New England, and South Atlantic divisions had higher estimated rates of childhood ADHD (55.1%, 53.6%, 49.3%, and 46.2% of the counties had rates of 16% or greater, respectively) compared to counties in the Mountain, Mid Atlantic, West North Central, Pacific, and East North Central divisions (2.1%, 4%, 5.8%, 6.9%, and 11.7% of the counties had rates of 16% or greater, respectively).

CONCLUSIONS

These local-level rates are useful for decision-makers to target programs and direct sufficient ADHD resources based on communities' needs.

Availability of hospital-based cancer services before and after rural hospital closure, 2008-2017

INTRODUCTION

Rural populations have less access to cancer care services and experience higher cancer mortality rates than their urban counterparts, which may be exacerbated by hospital closures. Our objective was to examine the impact of hospital closures on access to cancer-relevant hospital services across hospital service areas (HSAs).

METHODS

We used American Hospital Association survey data from 2008 to 2017 to examine the change in access to cancer-related screening and treatment services across rural HSAs that sustained hospitals over time, experienced any closures, or had all hospitals close. We performed a longitudinal analysis to assess the association between hospital closure occurrence and maintenance or loss of cancer-related service lines accounting for hospital and HSA-level characteristics. Maps were also developed to display changes in the availability of services across HSAs.

RESULTS

Of the 2,014 rural HSAs, 3.8% experienced at least 1 hospital closure during the study period, most occurring in the South. Among HSAs that experienced hospital closure, the loss of surgery services lines was most common, while hospital closures did not affect the availability of overall oncology and radiation services. Screening services either were stable (mammography) or increased (endoscopy) in areas with no closures.

DISCUSSION

Rural areas persistently experience less access to cancer treatment services, which has been exacerbated by hospital closures. Lack of Medicaid expansion in many Southern states and other policy impacts on hospital financial viability may play a role in this. Future research should explore the impact of closures on cancer treatment receipt and outcomes.

Changes in access to community health services among rural areas affected and unaffected by hospital closures between 2006 and 2018: A comparative interrupted time series study

PURPOSE

Recent studies suggest that Federally Qualified Health Centers (FQHC) may be expanding their provision of primary care in rural communities that experience a hospital loss. Whether these trends are different from rural areas not being affected by rural hospital closures is unknown.

METHODS

Data included Centers for Medicare and Medicaid Services Provider of Services files, the Cecil G. Sheps hospital closure database, and American Community Survey estimates. Changes in straight-line distances to the nearest FQHC and rural health clinic (RHC) were compared between areas affected and unaffected by a rural hospital closure in a matched case control study design using an interrupted time series model.

FINDINGS

There was no instantaneous percentage point increase in FQHC (2.41, 95% CI -0.79 to 5.60, P .140) or RHC (3.27, 95% CI -1.12 to 7.67, P .144) access following hospital closures compared to changes in access occurring in other rural areas. On average, rural ZIP codes affected by hospital closures exhibited a 0.84 percentage point increase in FQHC access over time (95% CI 0.40-1.28, P .000), but similar trends were also found within unaffected ZIP codes classified as small rural areas.

CONCLUSIONS

Rural areas impacted by hospital closures did not experience an increase in proximity to FQHCs or RHCs relative to changes in access occurring in other rural areas. Over time, most rural areas are seeing an increase in access to FQHCs and RHCs. Policies are needed to incentivize primary care providers to target geographic areas experiencing a hospital closure.

Examining the association between rurality and positive childhood experiences among a national sample

PURPOSE

The present study examines the association between rurality and positive childhood experiences (PCEs) among children and adolescents across all 50 states and the District of Columbia. Recent work has quantified the prevalence of PCEs at the national level, but these studies have been based on public use data files, which lack rurality information for 19 states.

METHODS

Data for this cross-sectional analysis were drawn from 2016 to 2018 National Survey of Children's Health (NSCH), using the full data set with restricted geographic data (n = 63,000). Descriptive statistics and bivariate analyses were used to calculate proportions and unadjusted associations. Multivariable regression models were used to examine the association between residence and the PCEs that were significant in the bivariate analyses.

FINDINGS

Rural children were more likely than urban children to be reported as having PCEs: volunteering in their community (aOR 1.29; 95% CI 1.18-1.42), having a guiding mentor (aOR 1.75; 95% CI 1.45-2.10), residing in a safe neighborhood (aOR 1.97; 95% CI 1.54-2.53), and residing in a supportive neighborhood (aOR 1.10; 95% CI 1.01-1.20) than urban children.

CONCLUSIONS

The assessment of rural-urban differences in PCEs using the full NSCH is a unique opportunity to quantify exposure to PCEs. Given the higher baseline rate of PCEs in rural than urban children, programs to increase opportunities for PCEs in urban communities are warranted. Future research should delve further into whether these PCEs translate to better mental health outcomes in rural children.

Rural-Urban Disparities in Quality of Inpatient Psychiatric Care

OBJECTIVE

Rural residents have higher rates of serious mental illness than urban residents, but little is known about the quality of inpatient psychiatric care available to them locally or how quality may have changed in response to federal initiatives. This study aimed to examine differences and changes in the quality of inpatient psychiatric care in rural and urban hospitals.

METHODS

This national retrospective study of 1,644 facilities examined facility-level annual quality-of-care data from the Inpatient Psychiatric Facility Quality Reporting program, 2015-2019. Facility location was categorized as urban, large rural, or small or isolated rural on the basis of zip code-level rural-urban commuting area codes. Generalized regression models were used to assess rural-urban differences in care quality (five continuity-of-care and two patient experience measures) and changes over time.

RESULTS

Rural inpatient psychiatric units performed better than urban units in nearly all domains. Improvements in quality of care (excluding follow-up care) were similar in rural and urban units. Rates of 30- and 7-day postdischarge follow-up care decreased in all hospitals but faster in rural units. Timely transmission of transition records was more frequent in small or isolated rural versus urban units (mean marginal difference=22.5, 95% CI=6.3-38.8). Physical restraint or seclusion use was less likely in rural than in urban units (OR=0.6, 95% CI=0.5-0.8).

CONCLUSIONS

Rural psychiatric units had better care quality at baseline (better follow-up care, better timely transmission of transition records, and lower rates of physical restraint use) than urban units, but during 2015-2019, follow-up care performance decreased overall and more in rural than urban units.

Interventions to address cancer-related financial toxicity: Recommendations from the field

PURPOSE

Addressing financial toxicity among cancer patients is a complex process that requires a multifaceted approach, particularly for rural patients who may face additional cost-related barriers to care. In this study, we examined interventions being implemented by financial navigation staff at various cancer centers that help address financial toxicity experienced by oncology patients.

METHODS

We conducted semistructured interviews with a convenience sample of financial navigation staff across 29 cancer centers in both rural and urban areas in 7 states. Interviews were audio-recorded and transcribed. Descriptive coding and thematic analysis techniques were used to analyze the data.

FINDINGS

Thirty-five participants were interviewed, the majority of whom worked in cancer centers located in rural counties. Participants identified the use of screening tools, patient education, and access to tailored financial assistance resources as best practices. Immediate resource needs included additional financial navigation staff, including lay navigators and community health workers, to promote linkages to local resources. Suggested clinical areas for intervention included proactive and early implementation of financial assessments and discussions between providers and patients, along with training and access to regularly updated resources for those in financial navigator/counselor roles. Participants also discussed the need for policy-level interventions to reform health systems (including employment protections) and health insurance programs.

CONCLUSIONS

Implementing proactive methods to screen for and address financial needs of patients is essential to improving cancer-related outcomes. Additional programs and research are needed to help establish systematic and standardized methods to enhance financial navigation services, especially for underserved rural communities.

SARS-CoV-2 Viral Incidence, Antibody Point Prevalence, Associated Population Characteristics, and Vaccine Attitudes, South Carolina, February 2021

The SARS-CoV-2 outbreak from October 2020 through February 2021 was the largest outbreak as of February 2021, and timely information on current representative prevalence, vaccination, and loss of prior antibody protection was unknown. In February 2021, the South Carolina Department of Health and Environmental Control conducted a random sampling point prevalence investigation consisting of viral and antibody testing and an associated health survey, after selecting participants aged ≥5 years using a population proportionate to size of South Carolina residents. A total of 1917 residents completed a viral test, 1803 completed an antibody test, and 1463 completed ≥1 test and a matched health survey. We found an incidence of 2.16 per 100 residents and seroprevalence of 16.4% among South Carolina residents aged ≥5 years. Undetectable immunoglobulin G and immunoglobulin M antibodies were noted in 28% of people with a previous positive test result, highlighting the need for targeted education among people who may be susceptible to reinfection. We also found a low rate of vaccine hesitancy in the state (13%). The results of this randomly selected surveillance and associated health survey have important implications for prospective COVID-19 public health response efforts. Most notably, this article provides a feasible framework for prompt rollout of a statewide evidence-based surveillance initiative.

Exploring Disparities in Youth Physical Activity Environments by Income and Non-Hispanic White Population Across the United States

This study investigated relationships between youth physical activity (PA) environments and income and non-Hispanic White population across the United States, stratified by US Census region and urban-rural designation. For all counties (n = 3142), publicly accessible data were used for sociodemographic indicators (ie, median household income and percent non-Hispanic White population) and a composite PA environment index (including exercise opportunities, violent crime incidence, walkability, and access to public schools). One-way analysis of variance was used to examine differences in PA environment index values according to income and non-Hispanic White population tertiles. There were significant differences in PA environments according to tertiles of income (F = 493.5, P < .001) and non-Hispanic White population (F = 58.6, P < .001), including variations by region and urban-rural designation. Public health practice and policy initiatives, such as joint use agreements, Safe Routes to School programs, and targeted funding allocations, should be used to address more pronounced income-based disparities in Southern and metropolitan counties and race-based disparities in rural and micropolitan counties.

Trends in Cancer Treatment Service Availability Across Critical Access Hospitals and Prospective Payment System Hospitals

BACKGROUND

Rural residents experience worse cancer prognosis and access to cancer care providers than their urban counterparts. Critical access hospitals (CAHs) represent over half of all rural community hospitals. However, research on cancer services provided within CAHs is limited.

OBJECTIVE

The objective of this study was to investigate trends in cancer services availability in urban and rural Prospective Payment System (PPS) hospitals and CAHs.

DESIGN

Retrospective, time-series analysis using data from 2008 to 2017 American Hospital Association Annual Surveys. Multivariable logistic regressions were used to examine differential trends in cancer services between urban PPS, rural PPS, and CAHs, overall and among small (<25 beds) hospitals.

SUBJECTS

All US acute care and cancer hospitals (4752 in 2008 to 4722 in 2017).

MEASURES

Primary outcomes include whether a hospital provided comprehensive oncology services, chemotherapy, and radiation therapy each year.

RESULTS

In 2008, CAHs were less likely to provide all cancer services, especially chemotherapy (30.4%) and radiation therapy (2.9%), compared with urban (64.4% and 43.8%, respectively) and rural PPS hospitals (42.0% and 23.3%, respectively). During 2008-2017, compared with similarly sized PPS hospitals, CAHs were more likely to provide oncology services and chemotherapy, but with decreasing trends. Radiation therapy availability between small PPS hospitals and CAHs did not differ.

CONCLUSIONS

Compared with all PPS hospitals, CAHs offered fewer cancer treatment services and experienced a decline in service capability over time. These differences in chemotherapy services were mainly driven by hospital size, as small urban and rural PPS hospitals had lower rates of chemotherapy than CAHs. Still, the lower rates of radiotherapy in CAHs highlight disproportionate challenges facing CAHs for some specialty services.

Definition and categorization of "rural" and assessment of realized access to care

OBJECTIVE

To examine how three measures of realized access to care vary by definitions and categorizations of "rural".

DATA SOURCES

Health Information National Trends Survey (HINTS) data, a nationally representative survey assessing knowledge of health-related information, were used. Participants were categorized by county-based Urban Influence Codes (UICs), Rural-Urban Continuum Codes (RUCCs), and census tract-based Rural-Urban Commuting Area (RUCAs).

STUDY DESIGN

Three approaches were used across categories of UICs, RUCCs, and RUCAs: 1) non-metropolitan/metropolitan, 2) 3-group categorization based upon population size, and 3) 3-group categorization based on adjacency to metropolitan areas. Wald Chi-square tests evaluated differences in sociodemographic variables and three measures of realized access across 3 of Penchansky's "A's of access" and approaches. The three outcome measures included: having a regular provider (realized availability), self-reported "excellent" quality of care (realized acceptability), and self-report of the provider "always" spending enough time with you (provider attentiveness--realized accommodation). The average marginal effects corresponding to each outcome were calculated.

DATA COLLECTION/EXTRACTION METHODS

N/A PRINCIPAL FINDINGS: All approaches indicated comparable variation in sociodemographics. In all approaches, RUCA-based categorizations showed differences in having a regular provider (e.g., 68.9% of non-metropolitan and 64.4% of metropolitan participants had a regular provider). This association was attenuated in multivariable analyses. No rural-urban differences in quality of care were seen in unadjusted or adjusted analyses regardless of approach. After adjustment for covariates, rural respondents reported greater provider attentiveness in some categorizations of rural compared to urban (e.g., non-metropolitan respondents reported 6.03 percentage point increase in probability of having an attentive provider [CI = 0.76-11.31%] compared to metropolitan).

CONCLUSIONS

Our findings underscore the importance of considering multiple definitions of rural to understand access disparities and suggest that continued research is needed to examine the interplay between potential and realized access. These findings have implications for federal funding, resource allocation, and identifying health disparities. This article is protected by copyright. All rights reserved.

The Problem Of The Color Line: Spatial Access To Hospital Services For Minoritized Racial And Ethnic Groups

Examining how spatial access to health care varies across geography is key to documenting structural inequalities in the United States. In this article and the accompanying StoryMap, our team identified ZIP Code Tabulation Areas (ZCTAs) with the largest share of minoritized racial and ethnic populations and measured distances to the nearest hospital offering emergency services, trauma care, obstetrics, outpatient surgery, intensive care, and cardiac care. In rural areas, ZCTAs with high Black or American Indian/Alaska Native representation were significantly farther from services than ZCTAs with high White representation. The opposite was true for urban ZCTAs, with high White ZCTAs being farther from most services. These patterns likely result from a combination of housing policies that restrict housing opportunities and federal health policies that are based on service provision rather than community need. The findings also illustrate the difficulty of using a single metric-distance-to investigate access to care on a national scale.

Racial Disparities and Diagnosis-to-Treatment Time Among Patients Diagnosed with Breast Cancer in South Carolina

OBJECTIVES

Diagnosis-to-treatment interval is an important quality measure that is recognized by the National Accreditation Program for Breast Centers, and the American Society of Breast Surgeons and the National Quality Measures for Breast Care. The aim of this study was to assess factors related to delays in receiving breast cancer treatment.

METHODS

This retrospective cohort study (2002 to 2010) used data from the South Carolina Central Cancer Registry (SCCCR) and Office of Revenue and Fiscal Affairs (RFA) to examine racial differences in diagnosis-to-treatment time (in days), with adjuvant hormone receipt, surgery, chemotherapy, and radiotherapy assessed separately. Chi-square tests, and logistic regression and generalized linear models were used to compare diagnosis-to-treatment days.

RESULTS

Black women on average received adjuvant hormone therapy, surgery, chemotherapy, and radiotherapy 25, 8, 7, and 3 days later than their White counterparts, respectively. Black women with local stage cancer had later time to surgery (OR: 1.6; CI: 1.2-2.2) compared with White women with local stage cancer. Black women living in rural areas had higher odds (OR: 2.0; CI: 1.1-3.7) of receiving late chemotherapy compared with White women living in rural areas. Unmarried Black women also had greater risk (OR: 2.0; CI: 1.0-4.0) of receiving late radiotherapy compared to married White women.

CONCLUSIONS

To improve timely receipt of effective BrCA treatments, programs aimed at reducing racial disparities may need to target subgroups of Black breast cancer patients based on their social determinants of health and geographic residence.

Residential Segregation and Emergency Department Utilization Among an Underserved Urban Emergency Department Sample in North Carolina

BACKGROUND Residential segregation is a spatial manifestation of structural racism. Racial disparities in emergency department (ED) utilization mirror social inequity in the larger community. We evaluated associations between residential segregation and ED utilization in a community with known disparities and geographically concentrated social and health risk.METHODS Cross-sectional data were collected from electronic medical records of 101 060 adult ED patients living in Mecklenburg County, North Carolina in 2017. Community context was measured as residential segregation using the dissimilarity index, categorized into quintiles (Q1-Q5) using 2013-2017 American Community Survey estimates, and residency in a public health priority area (PHPA). The outcome was measured as total ED visits during the study period. Associations between community context and ED utilization were modeled using Anderson's behavioral model of health service utilization, and estimated using negative binomial regression, including interaction terms by race.RESULTS Compared to areas with the lowest proportions of Black residents (Q1), living in Q4 was associated with higher rates of ED utilization among Black/Other (AME = 0.11) and White (AME = 0.23) patients, while associations with living in Q5 were approximately equivalent (AME = 0.12). PHPA residency was associated with higher rates of ED utilization among Black/Other (AME = 0.10) and White patients (AME = 0.22).LIMITATIONS Associations should not be interpreted as causal, or be generalized to the larger community without ED utilization. Health system leakage is possible but limited.CONCLUSIONS Residential segregation is associated with higher rates of ED utilization, as are PHPA residency and other individual-level determinants.

Abstract PO-118: Patient and county level determinants of surgical treatment for non-small cell lung cancer: A SEER-Medicare analysis

Introduction: Rural lung cancer patients experience worse survival than urban lung cancer patients. Worse survival in early-stage rural lung cancer patients may be due lower utilization of surgical treatment compared to their urban counterparts. We examined patient- and county-level determinants of surgical treatment for non-small cell lung cancer, focusing on rural vs. urban disparities. Methods: Our sample included 63,767 localized and regional NSCLC cases diagnosed between 2003-2011 using SEER-Medicare data. Predictors examined included demographics, clinical characteristics, and county factors (urban versus rural designation, percent of the population ≥65 years old below 100% Federal Poverty Limit, and designation as a Medically Underserved Area). Patient characteristics were nested within counties in multilevel logistic regression models stratified by stage at diagnosis, predicting receipt of surgical treatment. Results: Rural residents were less likely to receive surgical treatment than urban residents (42.0% vs. 46.8%, p&lt;0.01), and black patients were less likely than white patients to receive surgery (32.9% vs. 47.1%, p&lt;0.01). Rurality did not remain a significant factor in the final adjusted model. The final model showed an odds of surgical treatment decreased for every 5% increase in county-level poverty for both local stage (OR=0.83, 95% CI:0.77-0.91) and regional stage (OR=0.84, 95%CI: 0.79-0.90). Other patient factors associated with lower likelihood of surgical treatment included older age, male sex, non-married, dual Medicare/Medicaid enrollment, and more comorbidities. Conclusions: Rurality was not associated with receipt of surgery in the final multilevel model, but patient race and county-level poverty were significantly associated with a lower odds of surgery. Future research is needed to understand the causes of these disparities in surgical treatment of lung cancer to maximize survival for all populations.

Citation Format: Cassie Lewis Odahowski, Anthony J. Alberg, Mario Schootman, Jiajia Zhang, Jan M. Eberth. Patient and county level determinants of surgical treatment for non-small cell lung cancer: A SEER-Medicare analysis [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-118.

Estimates of Childhood Overweight and Obesity at the Region, State, and County Levels: A Multilevel Small-Area Estimation Approach

Local-level childhood overweight and obesity data are often used to implement and evaluate community programs, as well as allocate resources to combat overweight and obesity. The most current substate estimates of US childhood obesity use data collected in 2007. Using a spatial multilevel model and the 2016 National Survey of Children's Health, we estimated childhood overweight and obesity prevalence rates at the Census regional division, state, and county levels using small-area estimation with poststratification. A sample of 24,162 children aged 10-17 years was used to estimate a national overweight and obesity rate of 30.7% (95% confidence interval: 27.0%, 34.9%). There was substantial county-to-county variability (range, 7.0% to 80.9%), with 31 out of 3,143 counties having an overweight and obesity rate significantly different from the national rate. Estimates from counties located in the Pacific region had higher uncertainty than other regions, driven by a higher proportion of underrepresented sociodemographic groups. Child-level overweight and obesity was related to race/ethnicity, sex, parental highest education (P < 0.01 for all), county-level walkability (P = 0.03), and urban/rural designation (P = 0.02). Overweight and obesity remains a vital issue for US youth, with substantial area-level variability. The additional uncertainty for underrepresented groups shows surveys need to better target diverse samples.

Spatial clustering patterns and regional variations for food and physical activity environments across the United States

This study examined spatial patterns of obesogenic environments for US counties. We mapped the geographic dispersion of food and physical activity (PA) environments, assessed spatial clustering, and identified food and PA environment differences across U.S. regions and rurality categories. Substantial low food score clusters were located in the South and high score clusters in the Midwest and West. Low PA score clusters were located in the South and high score clusters in the Northeast and Midwest (p < .0001). For region, the South had significantly lower food and PA environment scores. For rurality, rural counties had significantly higher food environment scores and metropolitan counties had significantly higher PA environment scores (p < .0001). This study highlights geographic clustering and disparities in food and PA access nationwide. State and region-wide environmental inequalities may be targeted using structural interventions and policy initiatives to improve food and PA access.

The leading neighborhood-level predictors of drug overdose: A mixed machine learning and spatial approach

BACKGROUND

Drug overdose is a leading cause of unintentional death in the United States and has contributed significantly to a decline in life expectancy during recent years. To combat this health issue, this study aims to identify the leading neighborhood-level predictors of drug overdose and develop a model to predict areas at the highest risk of drug overdose using geographic information systems and machine learning (ML) techniques.

METHOD

Neighborhood-level (block group) predictors were grouped into three domains: socio-demographic factors, drug use variables, and protective resources. We explored different ML algorithms, accounting for spatial dependency, to identify leading predictors in each domain. Using geographically weighted regression and the best-performing ML algorithm, we combined the output prediction of three domains to produce a final ensemble model. The model performance was validated using classification evaluation metrics, spatial cross-validation, and spatial autocorrelation testing.

RESULTS

The variables contributing most to the predictive model included the proportion of households with food stamps, households with an annual income below $35,000, opioid prescription rate, smoking accessories expenditures, and accessibility to opioid treatment programs and hospitals. Compared to the error estimated from normal cross-validation, the generalized error of the model did not increase considerably in spatial cross-validation. The ensemble model using ML outperformed the GWR method.

CONCLUSION

This study identified strong neighborhood-level predictors that place a community at risk of experiencing drug overdoses, as well as protective factors. Our findings may shed light on several specific avenues for targeted intervention in neighborhoods at risk for high drug overdose burdens.

Social and demographic characteristics of frequent or high-charge emergency department users: A quantile regression application

OBJECTIVE

Heavy users of the emergency department (ED) are a heterogeneous population. Few studies have captured the social and demographic complexity of patients with the largest burden of ED use. Our objective was to model associations between social and demographic patient characteristics and quantiles of the distributions of ED use, defined as frequent and high-charge.

METHODS

We conducted a cross-sectional analysis of electronic health and billing records of 99 637 adults residing in an urban North Carolina county who visited an ED within Atrium Health, a large integrated health care system, in 2017. Mid-quantile and standard quantile regression models were used for count and continuous responses, respectively. Frequent and high-charge use outcomes were defined as the median (0.50) and upper quantiles (0.75, 0.95, 0.99) of the outcome distributions for total billed ED visits and associated charges during the study period. Patient characteristic predictors were: insurance coverage (Medicaid, Medicare, private, uninsured), total visits to ambulatory care during the study period (0, 1, >1), and patient demographics: age, gender, race, ethnicity, and living in an underprivileged community called a public health priority area (PHPA).

RESULTS

Results showed heterogeneous relationships that were stronger at higher quantiles. Having Medicaid or Medicare insurance was positively associated with ED visits and ED charges at most quantiles. Racial and geographic disparities were observed. Black patients had more ED visits and lower ED charges than their White counterparts at most quantiles of the outcome distributions. Patients living in PHPAs, had lower charges than their counterparts at the median but higher charges at the 0.95 and 0.99 quantiles.

CONCLUSIONS

The relationships between patient characteristics and frequent and high-charge use of the ED vary based on the level of use. These findings can be used to inform targeted interventions, tailored policy, and population health management initiatives.

Association between Neighborhood Social Deprivation and Stage at Diagnosis among Breast Cancer Patients in South Carolina

The purpose of this study was to examine the association between neighborhood social deprivation and individual-level characteristics on breast cancer staging in African American and white breast cancer patients. We established a retrospective cohort of patients with breast cancer diagnosed from 1996 to 2015 using the South Carolina Central Cancer Registry. We abstracted sociodemographic and clinical variables from the registry and linked these data to a county-level composite that captured neighborhood social conditions-the social deprivation index (SDI). Data were analyzed using chi-square tests, Student's t-test, and multivariable ordinal regression analysis to evaluate associations. The study sample included 52,803 female patients with breast cancer. Results from the multivariable ordinal regression model demonstrate that higher SDI (OR = 1.06, 95% CI: 1.02-1.10), African American race (OR = 1.35, 95% CI: 1.29-1.41), and being unmarried (OR = 1.17, 95% CI: 1.13-1.22) were associated with a distant stage at diagnosis. Higher tumor grade, younger age, and more recent year of diagnosis were also associated with distant-stage diagnosis. As a proxy for neighborhood context, the SDI can be used by cancer registries and related population-based studies to identify geographic areas that could be prioritized for cancer prevention and control efforts.

What is the place for space in epidemiology?

At the heart of spatial epidemiology is the need to describe and understand variation in population health. In this review and introduction to the themed issue on "Spatial Analysis and GIS in Epidemiology," we present theoretical foundations and methodological developments in spatial epidemiology, discuss spatial analytical techniques and their public health applications, and identify novel data sources and applications with the potential to make epidemiology more consequential. Challenges with using georeferenced data are also explored, including dealing with small sample sizes, missingness, generalizability, and geographic scale. Given the increasing availability of spatial data and visualization tools, we have an opportunity to overcome traditionally siloed fields and practice settings to advance knowledge and more appropriately respond to emerging public health crises.

Extent of Inclusion of "Rural" in Comprehensive Cancer Control Plans in the United States

Introduction

The National Comprehensive Cancer Control Program requires states, territories, and tribal organizations to develop comprehensive cancer control plans (CCCPs). In 2019, the National Advisory Committee on Rural Health and Human Services released a series of policy recommendations, including one recommending that CCCPs address rural cancer disparities. The objective of our study was to assess the extent to which jurisdictions considered “rural” in their CCCPs.

Methods

We reviewed the 66 CCCPs available on the Centers for Disease Control and Prevention’s website as of January 2020 to assess their inclusion of rural across 7 elements: 1) cancer burden data, 2) reduction of cancer disparities, 3) rural population description, 4) rural definition, 5) goals, 6) objectives, and 7) strategies. We summarized these elements by plan type (state or territory/tribal organization). For state CCCPs, we also compared the number of element types and the inclusion of rural-specific strategies by the percentage of the state’s population that was rural and the rural cancer mortality rate.

Results

Of 66 plans, 45 included a mention of rural in at least 1 element, including 38 of 50 state plans and 7 of 16 territory/tribal organization plans. Reduction of cancer disparities was the most common element noted. Less than one-third of all CCCPs included a rural-specific strategy. States with a high rural cancer mortality rate tended to have at least 1 rural-specific strategy.

Conclusion

Technical and financial support to improve rural data inclusion and implementation of rural-specific strategies in CCCPs may help improve the inclusion of rural data and strategy development.

Incongruency of youth food and physical activity environments in the United States: Variations by region, rurality, and income

Local environments are increasingly the focus of health behavior research and practice to reduce gaps between fruit/vegetable intake, physical activity (PA), and related guidelines. This study examined the congruency between youth food and PA environments and differences by region, rurality, and income across the United States. Food and PA environment data were obtained for all U.S. counties (N = 3142) using publicly available, secondary sources. Relationships between the food and PA environment tertiles was represented using five categories: 1) congruent-low (county falls in both the low food and PA tertiles), 2) congruent-high (county falls in both the high food and PA tertiles), 3) incongruent-food high/PA low (county falls in high food and low PA tertiles), 4) incongruent-food low/PA high (county falls in low food and high PA tertiles), and 5) intermediate food or PA (county falls in the intermediate tertile for food and/or PA). Results showed disparities in food and PA environment congruency according to region, rurality, and income (p < .0001 for each). Nearly 25% of counties had incongruent food and PA environments, with food high/PA low counties mostly in rural and low-income areas, and food low/PA high counties mostly in metropolitan and high-income areas. Approximately 8.7% of counties were considered congruent-high and were mostly located in the Northeast, metropolitan, and high-income areas. Congruent-low counties made up 10.0% of counties and were mostly in the South, rural, and low-income areas. National and regional disparities in environmental obesity determinants were identified that can inform targeted public health interventions.

COVID-19 risk mitigation behaviors among rural and urban community-dwelling older adults in summer, 2020

PURPOSE

Risk mitigation behaviors are important for older adults, who experience increased mortality risk from COVID-19. We examined these reported behaviors among rural and urban community-dwelling adults aged 65 and older.

METHODS

We analyzed public use files from the National Health and Aging Trends Study, which fielded a COVID survey from June to October, 2020, restricted to community-dwelling adults (n = 2,982). Eight behaviors were studied: handwashing, avoid touching face, mask wearing, limiting shopping, avoiding restaurants or bars, limiting gatherings, avoiding contact with those outside the household, and distancing. Residence was defined as urban (metropolitan county) or rural (nonmetropolitan county). Difference testing used Chi Square tests, with an alpha level of P = .05. Multivariable logistic regression was used to calculate adjusted odds ratios.

RESULTS

Rural residents constituted 18.8% (± Standard Error 3.6%) of the study population. In bivariate comparisons, rural older adults were less likely to report 5 of 8 studied behaviors: keep 6-foot distance (rural: 88.3% ±1.0%, urban 93.2% ±.08%), limit gatherings (rural 87.5% ±1.8%; urban 91.6% ±0.8%), avoid restaurants/bars (rural 85.3% ±1.9%, urban 89.6% ±0.8%), avoid touching face (rural 83.1% ±2.3%, urban 88.6%, 0.8%), and avoid contact with those outside the household (rural 80.4% ±2.4%, urban 86.2% ±1.0%). After adjusting for demographic characteristics, only maintaining a 6-foot distance remained lower among rural older adults (AOR 0.58, 95% CI: 0.42-0.81).

CONCLUSIONS

Within older adults, reported compliance with recommended behaviors to limit the spread of COVID-19 was high. Nonetheless, consistent rural shortfalls were noted. Findings highlight the need for rural-specific messaging strategies for future public health emergencies.

Associations of maternal stress and/or depressive symptoms with diet quality during pregnancy: a narrative review

BACKGROUND

Pregnancy can be a stressful time for many women; however, it is unclear if higher stress and depressive symptoms are associated with poorer diet quality during pregnancy.

OBJECTIVE

The aims for this narrative review were to (1) synthesize findings of original, peer-reviewed studies that examined associations of stress and/or depressive symptoms with diet quality during pregnancy; (2) review the measurement tools used to assess stress, depressive symptoms, and diet quality; (3) identify current gaps in the extant literature; and (4) offer recommendations for future research.

METHODS

A search strategy was used to identify peer-reviewed manuscripts published between January 1997 and October 2018, using the following databases: PubMed, CINAHL Complete, PsycINFO, Academic Search Complete, and Psychology & Behavioral Sciences Collection. The search was updated December 2019. Two reviewers independently assessed title, abstract, and full-text of the studies that met the inclusion criteria. Data were extracted and a quality assessment was conducted.

RESULTS

Twenty-seven observational studies were identified in this review (21 cross-sectional and 6 longitudinal). In 22 studies, higher stress and/or depressive symptoms were associated with poorer diet quality or unhealthy dietary patterns; 5 studies found no association. Findings are mixed and inconclusive regarding the relationship among stress, depressive symptoms, and food groups related to diet quality and frequency of fast-food consumption.

CONCLUSIONS

The current data suggest stress and depressive symptoms may be a barrier to proper diet quality during pregnancy; however, variability in the assessment tools, timing of assessments, and use of covariates likely contribute to the inconsistency in study findings. Gaps in the literature include limited use of longitudinal study designs, limited use of comprehensive diet-quality indices, underrepresentation of minority women, and lack of multilevel theoretical frameworks. Studies should address these factors to better assess associations of stress and/or depressive symptoms with diet quality during pregnancy.

Rural and racial disparities in colorectal cancer incidence and mortality in South Carolina, 1996 - 2016

PURPOSE

Colorectal cancer (CRC) is the third leading cause of cancer mortality among men and women in the United States and South Carolina (SC). Since SC has one of the highest proportions of Black (27.9%) and rural residents (33.7%), the purpose of this investigation was to describe the burden of CRC on racial disparities in rural populations.

METHODS

Count data from 2012 to 2016 were obtained from the state central cancer registry using an online data retrieval system. Rural-urban status was determined using Urban Influence Codes (1-2 = urban; 3-12 = rural). Chi-square tests were calculated to examine differences in CRC stage by rurality and race. Annual percent change and annual average percent change (AAPC) were calculated to examine trends in incidence and mortality rates across rural-urban and racial groups between 1996 and 2016.

RESULTS

Areas with high mortality-to-incidence ratios tended to be in rural counties. Furthermore, rural residents had higher proportions of distant stage CRC compared to urban residents, and Black populations had higher proportions of distant stage CRC compared to White populations (22.7% vs. 26.3% and 29.3% vs. 23.7%, respectively; P value < 0.05). From 1996 to 2016, Black and White urban-dwelling residents experienced a significant decline in incidence. Urban White, urban Black, and rural White populations experienced significant declines in mortality (AAPC = -2.6% vs -2.4% vs -1.6% vs -0.9%, respectively).

CONCLUSIONS

Despite improvements in CRC screening in recent decades, focused evidenced-based interventions for lowering incidence and mortality among rural and Black populations in South Carolina are necessary.

Facility Attractiveness and Social Vulnerability Impacts on Spatial Accessibility to Opioid Treatment Programs in South Carolina

Opioid dependence and opioid-related mortality have been increasing in recent years in the United States. Available and accessible treatments may result in a reduction of opioid-related mortality. This work describes the geographic variation of spatial accessibility to opioid treatment programs (OTPs) and identifies areas with poor access to care in South Carolina. The study develops a new index of access that builds on the two-step floating catchment area (2SFCA) method, and has three dimensions: a facility attractiveness index, defined by services rendered incorporated into the Huff Model; a facility catchment area, defined as a function of facility attractiveness to account for variable catchment size; and a Social Vulnerability Index (SVI) to account for nonspatial factors that mitigate or compound the impacts of spatial access to care. Results of the study indicate a significant variation in access to OTPs statewide. Spatial access to OTPs is low across the entire state except for in a limited number of metropolitan areas. The majority of the population with low access (85%) live in areas with a moderate-to-high levels of social vulnerability. This research provides more realistic estimates of access to care and aims to assist policymakers in better targeting disadvantaged areas for OTP program expansion and resource allocation.

Disparities in Meeting USPSTF Breast, Cervical, and Colorectal Cancer Screening Guidelines Among Women in the United States

INTRODUCTION

Many sociodemographic factors affect women's ability to meet cancer screening guidelines. Our objective was to examine which sociodemographic characteristics were associated with women meeting US Preventive Services Task Force (USPSTF) guidelines for breast, cervical, and colorectal cancer screening.

METHODS

We used 2018 Behavioral Risk Factor Surveillance System data to examine the association between sociodemographic variables, such as race/ethnicity, rurality, education, and insurance status, and self-reported cancer screening for breast, cervical, and colorectal cancer. We used multivariable log-binomial regression models to estimate adjusted prevalence ratios and 95% CIs.

RESULTS

Overall, the proportion of women meeting USPSTF guidelines for breast, cervical, and colorectal cancer screening was more than 70%. The prevalence of meeting screening guidelines was 6% to 10% greater among non-Hispanic Black women than among non-Hispanic White women across all 3 types of cancer screening. Women who lacked health insurance had a 26% to 39% lower screening prevalence across screening types than women with health insurance. Compared with women with $50,000 or more in annual household income, women with less than $50,000 in annual household income had a 3% to 8% lower screening prevalence across all 3 screening types. For colorectal cancer, the prevalence of screening was 7% less among women who lived in rural counties than among women in metropolitan counties.

CONCLUSION

Many women still do not meet current USPSTF guidelines for breast, cervical, and colorectal cancer screening. Screening disparities are persistent among socioeconomically disadvantaged groups, especially women with low incomes and without health insurance. To increase the prevalence of cancer screening and reduce disparities, interventions must focus on reducing economic barriers and improving access to care.

Stress and Depressive Symptoms Are Not Associated with Overall Diet Quality, But Are Associated with Aspects of Diet Quality in Pregnant Women in South Carolina

BACKGROUND

Poor mental health may hinder diet quality in pregnancy.

OBJECTIVE

This study 1) examined whether stress and depressive symptoms are associated with diet quality (via Healthy Eating Index [HEI] 2015 total scores and dietary intake of food groups/nutrients that align with HEI-2015 components) and 2) tested race as a moderator in the relationship between mental health and diet quality.

DESIGN

This was a cross-sectional analysis of baseline data from a randomized controlled trial collected January 2015 through January 2019 in Columbia, South Carolina. Trained staff administered demographic and psychosocial questionnaires and conducted anthropometric measures. Participants completed two 24-hour dietary recalls, which were self-administered (one on-site, one at home).

PARTICIPANTS

The Health in Pregnancy and Postpartum study was a randomized controlled trial targeting excessive gestational weight gain among pregnant women with overweight/obesity (N = 228).

MAIN OUTCOME MEASURES

The HEI-2015 total scores and food groups/nutrients that align with HEI-2015 were calculated.

STATISTICAL ANALYSES PERFORMED

Multiple linear regression models were used to estimate the relationship between mental health and HEI-2015 total scores and dietary intake of food groups or nutrients that align with HEI-2015 components. Multiplicative interaction terms of stress or depressive symptoms with race were used to determine moderation.

RESULTS

Participants' diet quality was suboptimal (M = 52.0 ± 11.7; range, 27-85). Stress was negatively associated with HEI-2015 total scores (crude but not adjusted model). Stress scores were positively associated with consumption of dairy, refined grains, and added sugars and negatively associated with total protein foods. Depressive symptoms were positively associated with consumption of dairy, refined grains, and saturated fats. Race was not a moderator.

CONCLUSIONS

Diet quality was poor overall, but stress and depressive symptoms were not associated with HEI-2015 total scores in adjusted models. Excluding dairy, stress and depressive symptoms were associated with the consumption of food groups or nutrients related to worse diet quality. These relationships should be examined longitudinally to help establish causality and inform future interventions.

A spatial assessment of prostate cancer mortality-to-incidence ratios among South Carolina veterans: 1999-2015

PURPOSE

To assess veteran-specific prostate cancer (PrCA) mortality-to-incidence ratios (MIR) in South Carolina's (SC) veteran population.

METHODS

U.S. Veterans Health Administration electronic medical records from January 1999 to December 2015 identified 3,073 PrCA patients residing in 345 ZIP code tabulation areas (ZCTA) within SC. MIRs were calculated for all SC ZCTAs and by key patient- and neighborhood-level risk factors for PrCA. Comparisons between ZCTAs identified as part of a spatial cluster were compared with non-significant ZCTAs using t tests.

RESULTS

The MIR was 0.17 overall, ranging from a low of 0.15 among Black men to 0.20 among White men. Among metropolitan ZCTAs, the MIR was 0.18 compared to 0.16 in non-metropolitan ZCTAs. Two clusters of higher-than-expected MIRs were found in the Upstate region.

CONCLUSIONS

Identification of spatial clusters of higher- or lower-than-expected MIRs allows for further testing of possible explanatory factors, and the capacity to target resources and policies according to greatest need.

Low-dose CT lung cancer screening uptake: A rural-urban comparison

PURPOSE

The US Preventive Services Task Force recommends lung cancer screening with Low-Dose Computed Tomography (LDCT) in high-risk individuals. Our objective was to identify demographic, health, and financial factors associated with screening uptake, with a focus on urban-rural differences.

METHODS

We analyzed data from the 2018 and 2019 Behavioral Risk Factor Surveillance System and its optional Lung Cancer Screening Module to examine factors associated with screening uptake among 20 states that administered the optional module. We compared differences in factors associated with uptake overall and by geographical regions and conducted multivariable logistic mixed-effects regression, accounting for participant clustering by state to assess the impact of these factors on uptake.

FINDINGS

Overall 1,268 participants underwent LDCT screening with no significant differences observed between rural (16.3%) and urban residents (17.7%, p = 0.67). In multivariable models, rural residents did not differ significantly in their LDCT screening uptake (OR = 0.85; 95% CI: 0.67-1.09, p = 0.20), but uptake was significantly higher for participants with underlying chronic respiratory conditions, veterans, those with higher pack-year history, and those with poor/fair general health and prior history of cancer. Uptake declined with age, higher education level, concerns about paying for medical care, and lack of primary care.

CONCLUSIONS

Modifiable targets can be leveraged to increase LDCT screening. Based on significant predictors of screening uptake, clinicians should prioritize interventions that effectively consider smoking history as well as those identified as effective in veterans' health settings. Additionally, reducing structural barriers to care related to insurance and income will be key to reducing disparities.

Trends in spatial access to colonoscopy in South Carolina, 2000-2014

BACKGROUND

Colonoscopy use has increased since Medicare began covering screening for average-risk persons. Our objective was to describe changes in spatial access to colonoscopy in South Carolina (SC) between 2000 and 2014.

METHODS

Using data from the SC Ambulatory Surgery Database, we created annual ZIP Code Tabulation Area (ZCTA) spatial accessibility scores. We assessed changes in accessibility, colonoscopy supply, and potential demand, overall and by metropolitan designation. Spatial clustering was also explored.

RESULTS

Spatial accessibility decreased across both small rural and metropolitan ZCTAs but was significantly higher in metropolitan areas during the first part of the study period . The proportion of persons with no access to colonoscopy within 30 min increased over time but was consistently higher in small rural areas. Clusters of low accessibility grew over time.

CONCLUSIONS

The supply of colonoscopy facilities decreased relative to the potential demand, and clusters of low access increased, indicating a contraction of services.

Healthy Food Density is Not Associated With Diet Quality Among Pregnant Women With Overweight/Obesity in South Carolina

OBJECTIVE

Examine the association and moderating effect of residential location (urban/rural) on the relationship between neighborhood healthy food density and diet quality.

DESIGN

Cross-sectional analysis of baseline data from the Health in Pregnancy and Postpartum study, a randomized trial designed to prevent excessive gestational weight gain.

PARTICIPANTS

Pregnant women in South Carolina with prepregnancy overweight/obesity (n = 228).

MAIN OUTCOME MEASURES

Healthy Eating Index-2015 (HEI) was used to measure diet quality from 2 24-hour dietary recalls. The HEI total scores and 11 binary HEI components (those that met the standard for maximum component score vs those that did not) were calculated as dependent variables.

ANALYSIS

Multiple linear and logistic regression models were used to examine the association between healthy food density and HEI total scores and meeting the standards for maximum component scores. Healthy food density × residential location tested for moderation. P < 0.05 indicated significance.

RESULTS

Participants' diet quality was suboptimal (mean, 52.0; SD, 11.7; range, 27-85). Healthy food density was not significantly related to HEI total scores or components, and residential location was not a moderator.

CONCLUSIONS AND IMPLICATIONS

Diet quality was suboptimal, and there was no relationship between healthy food density and diet quality among Health in Pregnancy and Postpartum study participants. These data support examining behavioral factors that could influence diet quality.